vicarious trauma in legal practice
TRANSCRIPT
Vicarious Trauma in Legal Practice
The Newcastle Club
6pm, 21 September 2017
Dr Colin James
ANU School of Legal Practice, ANU College of Law
University of Newcastle
Originally ..
• Physical trauma – still common in medical discourse
Popular meaning - ‘psychic’ or ‘psychological’ injury
• a psychologically upsetting experience that produces an emotional or mental disorder or otherwise has lasting negative effects on the person's thoughts feelings or behaviour
• an emotional wound or shock that has negative long lasting effects
• any event having an acute adverse psychological effect
‘DV trauma can impact children in later life’
• Pena et al, Science 16 Jun 2017: Vol. 356, Issue 6343, pp. 1185-1188 DOI: 10.1126/science.aan4491
• ‘stress’
• (mice)
Traumatic impacts
• High job turnover - 30-60% of social workers in ‘high impact’
areas like child abuse leave their job each year (US)
Eg. 2014, Robinson-Keilig, ‘Secondary Traumatic Stress and Disruptions to Interpersonal Functioning Among Mental Health Therapists’, Journal of Interpersonal Violence 29(8)
Judith Herman MD - 1992
Psychological trauma:
• ‘Hysteria’ of women
• Sexual and domestic violence
‘..violence is a routine part of women’s sexual and domestic lives. Freud glimpsed the truth and retreated in horror’ (p.28)
Allan Young - 1995
PTSD was not discovered, but invented
• Vietnam vets
• .. urban, perpetrator, observing, social, cultural, first responder, DV, psychiatric, …
• 95% of research & discussion about trauma is (problematically) located in western developed Nations
What is it about ‘Western culture’ that makes us prone to trauma?• Culture can have biological effects, eg - East Asians tend
to deemphasize positive affect. In this 2017 study, positive affect was associated with healthier lipid profiles for Americans but not for Japanese. http://journals.sagepub.com/doi/full/10.1177/0956797617713309#
• In an earlier publication, Prof Ronnie Janoff-Bulman says Westerners have 3 deep-seated beliefs
1. The world is benevolent2. The world is meaningful, controllable and predictable3. We assume we are good, worthy and decent
- Ronnie Janoff-Bulman, ‘Shattered Assumptions: Towards a new psychology of trauma’ (1992)
For Westerners, trauma is ‘the atom smasher of our belief systems…(when) our scaffolding comes crashing down’
Prof. Mark S Micale (Illinois) –2001 (2010)
Newcastle City Hall, 1 June 2017
• 1870s - psychic shock
• 1915 - shell shock
• 1945 - war neurosis
• 1980 - PTSD(DSM III– the ‘formal birthing’)
E. Ann Kaplan - 2015
• …the ‘slow violence’ of ‘pre-traumatic stress disorder’ humans are inflicting on the planet.
Communication Monographs
Volume 55, 1988 - Issue 3
Occupational Burnout
• The “burnout syndrome” has been defined as a combination of emotional exhaustion, depersonalization, and reduced personal accomplishment caused by chronic occupational stress.
- Bianchi et al (2015)
International Coaching Psychology Review l Vol. 12 No. 1 March 2017
QualitativeN = 4Personal and protective growth can follow ‘executive derailment’
Occupational Burnout
• Exhaustion, lack of enthusiasm, low motivation, critical self-talk
• Attitude at work – cynicism, apathy, pessimism, reduced efficacy and engagement
• Chronic fatigue, panic attacks, headaches
• Inability to relax or to ‘do nothing’
• Physical symptoms – chest pain, stomach pain, reduced appetite, heart palpitations..
- Carter 2006
Signs & Symptoms
Secondary Trauma Stress (STS)Compassion Fatigue - Similar constructs
What is it?
• STS first appeared with DSM-4 in 1994
• Psych stress (distress?) from exposure to a client’s trauma
• ‘a set of psychological symptoms that mimic PTSD, but is acquired through exposure to persons suffering the effects of trauma’
– Baird & Kracen 2006
Secondary Trauma Stress (STS)Compassion Fatigue - Similar constructs
Signs & Symptoms
• Somatic complaints (body pain, sleep, appetite), fear/anxiety, intrusive images, avoidance of clients
• Diminished capacity
• Cynicism/ Loss of empathy (a defence)
Volume 199, Number 12, December 2011
N = 238 attorneys Wisconsin State Public Defender Office
N = 109 support staffTests 1. PTSD symptoms (DSM-IV),
2. Depression scale3. Professional quality of life scale
Levine et al, 2011
• 75% met criteria for ‘functional impairment’
• 34% of attorneys met criteria for STS
• 11% met clinical criteria for PTSD
NB: Sex, age, years on the job, office size, and personal history of trauma did not predict symptoms (contra Vrlevski and Franklin - 2008)
ABA – January 2017
The Case Against VT
ICD -11 (Beta) makes no reference to vicarious trauma (or STS)
Vicarious Trauma (a different ballpark)
• ‘..it is more than just the stress of overwork; it is a disintegrating ray gun aimed at your sense of who you are, what you think the world is like, and where you find meaning in the world.’
- Peters, Silver & Portnoy (2004)Yale Law School Legal Scholarship Repository
Vicarious Trauma (a different ballpark)
• harmful changes that occur in professionals’ views of themselves, others, and the world, as a result of exposure to the graphic and/or traumatic material of their clients.
- Baird & Kracen 2006Counselling Psychology Quarterly, June 2006; 19(2): 181–188
9/11 survivor research
‘And we looked up and it was the aeroplane coming right at us, the second plane. And all I remember saying, was ‘Oh dear God just take my soul’.
And as it was coming towards us, I could see the pilot and there was absolutely no expression on this man’s face at all…..’
- Greenall & Marselle 2007The Psychologist Vol 20 No 9
9/11 survivor research
‘And we looked up and it was the aeroplane coming right at us, the second plane. And all I remember saying, was ‘Oh dear God just take my soul’.
And as it was coming towards us, I could see the pilot and there was absolutely no expression on this man’s face at all…..’
…, we sometimes found ourselves psychologically affected by what we were researching. Indeed, on more than one occasion during these interviews, we had tears in our eyes and almost had to halt some interviews for our own benefit, let alone the participant’s.
- Greenall & Marselle 2007The Psychologist Vol 20 No 9
The (real) birth of Vicarious Trauma
The birth of Vicarious Trauma
• DSM 5 (2013) after 9/11
• DSM inclusion of VT helped de-stigmatize the reactions of first responders and reinforce the need for wellness training and post-exposure care.
Vicarious Trauma
(some) Signs and Symptoms
• Change in self-concept, cognitive changes, unusual negative thoughts about self and others, reduced sense of safety, reduced trust in others, sense of impending doom
• Hypervigilance, low mood, anxiety, appetite, sleep, anxiety, intrusive disturbing images
• Increased absenteeism, reduced efficacy, drop out from workforce
Vicarious Trauma
Can impact broadly:
• Emotional symptoms
• Behavioral symptoms
• Physiological symptoms
• Cognitive symptoms
• Spiritual symptoms (hope, optimism)
Vicarious Trauma – some risk factors
• Feeling isolated
• Lack of supervision
• Occupational burnout
• Too much work
• High compassion
• Personal trauma history (contentious)
• Poor coping strategies
• Personal stresses
Is VT about ‘too much empathy’?
• Paul Bloom (2016) Against Empathy
- Moral empathy (bad)
- Empathy is biased, stupid, innumerate, illogical, dangerous, short-sighted, parochial, can spark violence, it fails morality, and is corrosive of personal relationships
- Cognitive empathy/ compassion (good)
Post-traumatic Growth?
• PTG is not the opposite of PTSD
- they often go hand in hand
• PTG is the process of change not the outcome.
Post-traumatic Growth?
5 potential benefits of PTG • "Finding personal strength, forming deeper
relationships, discovering more meaning in life and seeing new possibilities“
(It won’t just happen –
you have to work on it)
• Viktor Frankl "in some way suffering ceases to be suffering at the moment it finds meaning".
Post-traumatic Growth?
• PTG is seen in some trauma survivors who report
- improved relationships,
- new possibilities for one’s life,
- a greater appreciation of life and personal strength,
- and spiritual development
- Tedeschi & Calhoun, 1995, 2004
Post-traumatic Growth?
30 – 70% trauma survivors report some form of subsequent benefit.
PTG has been confirmed in several US studies of people who experienced
• cancer (Cordova, Cunninham, & Carlson, 2001),
• sexual assault (Frazier & Berman, 2008).
• the 9/11 terrorist attacks (Park, Aldwin, Fenster, & Snyder, 2008)
However studies in other countries have yielded ‘divergent’ results.
9/11 Victim Recovery and Growth
N =1,382, 72% white, 51% women.Poulin et al, 2009.
(Lawyers have)…
‘an ethical duty ..to attend to the ways in which trauma and vicarious trauma disrupt ourselves and to repair that on a regular basis.
Peters et al, 2004, 854
(because)
Without that kind of careful, ongoing care of ourselves and of the things that give us meaning, we would eventually have nothing to give our clients and no resources through which to render service.’
Peters et al, 2004, 854
Five (validated) strategies - likely to enhance
meaning in life which may improve individual resilience against Vicarious Trauma, STS, Compassion Fatigue and Burnout
• Self-determination Theory
• Broaden and Build Theory of Positive Emotions
• VIA Character Strengths
• Professional Quality of Life – ProQoL
• Mindfulness practice
Self-Determination Theory (SDT)
Ryan & Deci (2000, 2017) - ‘intrinsic motivation’ requires the satisfaction of three psychological needs:
• Autonomy
• Competence
• Relatedness
Similarly, ‘…to enhance and promote the natural tendency toward eudaimonic well-being’
- Joseph, 2011 p.112
Broaden-and-Build Theory
• Positive emotions broaden people’s ‘momentary thought-action repertoire’.
- Barbara Fredrickson (1998, 2001, 2004, 2008)
VIA – Character Strengthshttps://www.viacharacter.org/www
Results revealed significant, positive correlations showing virtues predicted posttraumatic growth
(Duan & Guo, 2015)
and trait resilience was a strong predictor of PTSD
(Duan, Guo, & Gan, 2015)
Professional Quality of Life
Compassion Satisfaction
• The positive aspectsof helping
Compassion Fatigue
• The negative aspects of helping
(Jang et al, 2016)
Professional Quality of Life
Compassion Satisfaction
Compassion Fatigue
BurnoutSecondary
Trauma
Enhancing professionalism by ‘doing compassion’ better
Tania Singer -‘Cognitive Perspective Taking’
Strategies for enhancing compassion have meas. effects on attitude and resilience.
https://www.youtube.com/watch?v=n-hKS4rucTY
Higher professionalism leads to higher
compassion satisfaction, and lower compassion fatigue.
Vicarious Resilience
• ..in response to client trauma survivors’ own resiliency
- Hernández, Gangsei, & Engstrom, 2007
• ..a unique consequence of trauma work
- Sally Hunter 2012
Methods used by participants to develop vicarious resilience in this study (inter alia):- reflecting on human beings’ capacity to heal - regaining hope - educating others about the effects of violence by
writing and speaking opportunities
“WE CAN’T PRACTICE COMPASSION WITH OTHER PEOPLE IF WE DON’T TREAT OURSELVES KINDLY.” Brene Brown, Social Worker
https://www.ted.com/talks/brene_brown_on_vulnerability
VULNERABILITY – HOPE - OPTIMISM
One Highlight
• Mindfulness-based treatments are effective in ameliorating symptoms of PTSD.
N = 632 over 6 months‘…when people work to improve the welfare of other people, theyexperience more meaningfulness in their work. (leading to) increasing the personal well-being of workers and the productivity of organizations.
Organisational Support
Organisational Support (my top three)
• Enhance EAP support, supervision & CPD training on trauma-affected work, (insulate against stigma)
• Encourage frequent breaks, case-load supervision and no overworking
• Implement a de-briefing protocol
Foster a safe and supporting environment:
Critical Incident Stress Debriefing: CISD (US)
- International Critical Incident Stress FoundationHome Page of Jeff Mitchell's ICISF includes information about critical stress debriefing.
- CISD Reference List, compiled by Dr. Atle DyregrovAn updated listing of published research on critical incident stress, psychological debriefings, and related group work.
- A Critical View on Debriefing, by Richard Gist, PhDRichard Gist summarizes concerns surrounding critical incident debriefing, including references to additional literature.
Other resources (US)
• David Baldwin's Trauma Pages: www.trauma-pages.com
• Eye Movement Desensitization and Reprocessing International Assoc.: www.emdria.org
• The Center for Self-Leadership (IFS): ww.selfleadership.org
• International Society for Traumatic Stress Studies: www.istss.org
• Jim Hopper's Trauma Website: www.jimhopper.com
Personal Support - step back for perspective
• Visualize an observer (fly on the wall)
• Self-talk in third person (‘you can do this’) https://www.nature.com/articles/s41598-017-04047-3
• Write about it (journaling – what is important and why) https://pdfs.semanticscholar.org/db65/d3eec48e82b8895c11711554852deac29f62.pdf
• Your future take – imagine and reflect from 1 week in the future, then a year, then 10 years
Strategies for self-distancing
Personal Support - my top three for enhancing resilience to VT, STS, CF and BO
• Mindfulness• Wherever you go, there you are – Jon Kabat-Zinn
• Wherever you are, make sure you’re there - Dan Sullivan
• How to meditate when you can’t sit still - https://tinyurl.com/y9vhgngv
• Fitness (food & sleep) regime/ yoga - (habits)
• Friends and relationships
Ok, two more…
• Watch your boundaries: don’t be ‘the rescuer’
• Stay loose, use humour, and don’t over-analyse: iatrogenic risk
Individual and workplace resources & assessments 1• Values in Action (VIA) Character Strengths survey -
https://www.viacharacter.org/www/
• Professional Quality of Life scale - ProQOL.org or http://www.proqol.org/uploads/ProQOL_5_English_Self-Score_3-2012.pdf
• Secondary Trauma Stress scale -https://www.researchgate.net/publication/254364576_The_Secondary_Traumatic_Stress_Scale_STSS
• Psychological First Aid -http://www.redcross.org.au/files/Psychological_First_Aid_An_Australian_Guide.pdf
Individual and workplace resources & assessments 11• Resources about Trauma-Informed Care -
https://indianajuvenilejustice.com/2013/09/24/resources-about-trauma-informed-care/
• Healing Power How to keep legal minds intact by mitigating compassion fatigue -https://www.texasbar.com/AM/Template.cfm?Section=Past_Issues&Template=/CM/ContentDisplay.cfm&ContentID=24119
• Secondary trauma & compassion fatigue when working with clients in crisis -https://www.law.washington.edu/pservice/probono/reducingsecondarytrauma.pdf
• Compassion Fatigue (ABA) -https://www.americanbar.org/groups/lawyer_assistance/resources/compassion_fatigue.html
Selected Resources 1
• 1991 - Martin E. P. Seligman, Learned Optimism: How to Change Your Mind and Your Life (New York: Pocket Books, 1991).
• 2004 - Koh, Silver & Portnoy (2004) Stress, Burnout, Vicarious Trauma, and Other Emotional Realities in the Lawyer/Client Relationship: A Panel Discussion http://tinyurl.com/y7qotoan
• 2004 – Palm et al - Vicarious Traumatization: Potential Hazards and Interventions for Disaster and Trauma Workers Prehosp Disast Med 2004;19(1):73–78 https://tinyurl.com/ybvv4rw7
• 2004 – Linley & Joseph – ‘Positive change following trauma and adversity: A review’ Journal of Traumatic Stress
• 2006 – Carter – ‘When the Enemy Lies Within: Risk for Professional Burnout Among Family Lawyers’ American Journal of Family Law
• 2006 – Helgeson et al – ‘A meta-analytic review of benefit finding and growth’. Journal of Consulting and Clin Psych, 74, 797-816
• 2007 – Greenall & Marsalle – ‘Traumatic research: Interviewing survivors of 9/11’ The Psychologist http://thepsychologist.bps.org.uk/volume-20/edition-9/traumatic-research-interviewing-survivors-911
Selected Resources 11
• 2007 – Hernandez et al - Vicarious Resilience: A New Concept in Work With Those Who Survive Trauma, Family Process, Vol. 46, No. 2 http://www.nursingacademy.com/uploads/6/4/8/8/6488931/vicariousresilience.pdf
• 2008 - Pealman & McKay - Understanding and Addressing Vicarious Trauma http://www.headington-institute.org/files/vtmoduletemplate2_ready_v2_85791.pdf
• 2008 – Levin - Secondary Trauma and Burnout in Attorneys: Effects of Work with Clients Who are Victims of Domestic Violence and Abuse (ABA) https://www.americanbar.org/content/dam/aba/publishing/cdv_enewsletter/LevinWinter2008.authcheckdam.pdf
• 2011 – Stephen Joseph – ‘What Doesn’t Kill Us - The New Psychology of Post-Traumatic Growth’
• 2015 - Duan, W., & Guo, P. Association between virtues and posttraumatic growth: Preliminary evidence from a Chinese community sample after earthquakes. PeerJ, 3, e883. https://dx.doi.org/10.7717/peerj.883 2.
• 2015 - Duan, W., Guo, P., & Gan, P. Relationships among trait resilience, virtues, post-traumatic stress disorder, and post-traumatic growth. PLOS One. DOI: 10.1371/journal.pone.0125707
• 2016 – Jang et al, Professionalism and professional quality of life for oncology nurses, J Clin Nurs. 2016 Oct;25(19-20):2835-45. doi: 10.1111/jocn.13330. Epub2016 Jun 23.
Selected Resources 111
• 2015 – Tania Singer, The Neuroscience of Compassion (World Economic Forum) https://www.youtube.com/watch?v=n-hKS4rucTY
• 2016 - Steven F. Maier and Martin E. P. Seligman, “Learned Helplessness at Fifty: Insights from Neuroscience,” Psychological Review 123 (2016): 349–67 https://www.ncbi.nlm.nih.gov/pubmed/27337390
• 2016 – ABA -Understanding The Impact Of Secondary Trauma On Lawyers Working With Children And Families https://www.americanbar.org/content/dam/aba/multimedia/cle/materials/2016/05/ce1605cal.authcheckdam.pdf
• 2017 – Steckler & Light - The Hidden Cost of Empathy: How to Address Secondary Trauma Stress in a Child Law Office (ABA) https://www.americanbar.org/publications/litigation-committees/childrens-rights/articles/2017/hidden-cost-of-empathy-how-to-address-sts-child-law-office.html
• 2017 - Sandberg, Sheryl. Option B: Facing Adversity, Building Resilience, and Finding Joy (p. 176). Ebury Publishing. Kindle Edition.
• 2017 – Ryan & Deci - Self-Determination Theory: Basic Psychological Needs in Motivation, Development, and Wellness, https://www.guilford.com/books/Self-Determination-Theory/Ryan-Deci/9781462528769
• 2017 - Psychological First Aid in Australia – APS and Red Cross http://www.redcross.org.au/files/Psychological_First_Aid_An_Australian_Guide.pdf
Thank you